Failure to Provide and Document Wound Care per Professional Standards
Penalty
Summary
The facility failed to maintain professional standards of practice in providing wound care for a resident with a Stage 4 pressure ulcer to the sacrum and moisture-associated skin damage (MASD) to the left medial thigh. Physician orders specified wound care regimens for both the sacral wound and the left lower leg, including cleansing, application of specific dressings, and covering with appropriate materials. Review of the Treatment Administration Record (TAR) indicated that wound treatments were documented as completed on several dates by a licensed nurse. However, during an observation, the resident was found with loose dressings on both legs, one of which was dated several days prior, and the sacral wound was left open to air without a dressing, contrary to physician orders. In an interview, the nurse responsible for the resident's care admitted to documenting that wound treatments had been performed when, in fact, they had not been completed for the day. The nurse was unable to confirm whether treatments had been performed on the dates documented, as the dressing dates did not correspond with the recorded entries. This failure to provide wound care as ordered and to accurately document care provided resulted in noncompliance with professional standards and facility policy.